GW1-2021-01159_Well Construction - GW1_20210809

Y
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.NVell Conti-actor Information:
Kyle C. Shaw 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. I R, i l
4521-A ,t ,t. ! i
NC Well Contractor Certification Number 15.OUTER CAY (for multi-caedwells) Ra ticable
T D1AETAdvanced Well Drilling, LLC FRO
MATERIAL
ft 5 ft ;6 ln. Heavy PVC
Company Name
} ( ' (9�J 16.Irti1ER CASING OR TUBING(geothermal closed-lob
i.. 2.�t'ell Construction Permit#:�1 1�++�I " FRoat TO DIAMETER TnICINESS MATERIAL
List all applicable well cautnrction pemtits fl.e. UIC.Count.State,Mariance,etc.) fL ft in
3.dell Use(check well use): ft in.
Iv Well: 17.SCREEN
Water Supply FROM TO DLAlIfEtER SLOT SIZE TRICI{,'ESS dL1TERIAL
❑:4gricutturai OManicipal/Public ft M in.
❑Geothermal(Heating/Cooling Supply) 15Residential Water Supply(single) it. ft in.
❑industrial/Commercial ❑Residential Rater Supply(shared) 18.GROUT
Olnigation O Wells>100.000 GPD FROM TO 1L4TERIAL -E\IPL&CENIE\'T METHOD&AtMOUNT
Non-Water Supply Nrtell: 0 ft. cjSa ft Bentonite Poured
❑Monitoring ORecovery it fL
Injection Well: p• n,
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK tfa 'Iicabte
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EAIPL4CVNIM 'METROD
❑Aquifer Test OStornmater Drainage fl. ft
OEtperimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed loop) OTraeer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness,soNrock type,grain size,etch
❑Geothermal(HeatingiCooling Return) ❑Odier(explain under#21 Remarks) o It tkA
4.Date-%Vell(s)Completed: "i`�`� Well ID# fL
ft
5a.Well Location: v 7 P �-
i % M
r�,1IG9�l,X firetytt. Cs�l� �.
Facility/Owner Name Facilit.%ID4'(ifapplicable) R D
ft tt
Physical Address,Cs, i d Zip ft. Q
ub
21.REMARKS --acAna
County Parcel Identification No.(PIN) Vorl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/long is sufficient) 22.Certification:
,41�11&,,r
6.Is(are)the well(s): ,Permanent or OTemporary SiPnati&of Certified Well Contractor Date
By signing this form,I hereby certi6-that the ivell(s)was(were)constntcted in accordance i:dth
7.Is this a repair to an existing well: ❑Yes or 8 No 15.4 VC4C 02C.0100 or 1 SA NCAC 02C.0200 Melt Constntction Standards and that a copy
If this is a repair,fill out known trell consintction information and explain the nantre of the of this record has been provided to the well owner.
repair under 421 remarks section or on tire back ofthis form 23.Site diagram or additional yell details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional«ell construction info
construction,only 1 GVd-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pagan if necassan.
drilled: 24.STIBIVHTT L INSTRUCTIONS
9.Tote well depth below land surfacer (ft.) Submit this GNV-1 within 30 days of well completion per the following:
Par nndtiple wells list all depths,if dit)erent(example-3C,200'and 2@100')
P; 24a. For All «'ells: Original fonn to Division of Water Resources (DWR).
10.Static water level below top of casing: // (ft-) Information Processing Unit,1617 MSC.Raleigh,NC 27699-1617
If water level is above casing,use"="
il.Borehole diameter 6 {rn) 24b.For Injection R'ells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 NISC,Raleigh,NTC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le auger,rotary,cable,direct push,etc.) county environnmenW health department of the county where installed
FOR AVATER SUPPLY ANTLLS UNIX: 24d.For Water Wells
roduc'' over 100 000 GPD:Copy to DWI?,CCPCUA
13a.Yield(gpm) Method of test:
Air PerPermitProgram, 161 I MSC,1Wel . NC 276 -1611
� ? ftt
13b.Disinfection t♦pe: HTH Amount:
'norm Gwt-I North Carolina Department of Environmental Quality-Division of Water Resources Reviscd 6.6?0l S .

LINCOLN COUNTY HEALTH DEPARTMENT
115 West Main Street-LINCOLNTON,N.C.28092•PHONE:[phone]-FAX: [phone]
Permit#: EHW21-03027 Parcel Id#:1102993
a
Owner. HOLLAND TRENTON COLE Phone:
Address: 6938 JEFFERSON DR ":= City: DENVER State: NC Zip: 28037
Applicant: Phone:
Address: City: State: Zip:
Location FORNEY HILL RDA Sub: BOB BEAL ESTATE PROPERTY Lot#: SA
LOT 5A
WELL CONSTRUCTION PERMIT
-,ter rn
la
100
le
.� y • ^ ` K*4p house. �' C7arnjv-
t� 7 / SIZe f pos;+;7 ►
p Ana mz 4&rs .5144n hVIL1
\ off Qo-� �f'y_ •�f+►1; -}D AVoi d enClroat hIIA
on sap4i Sys
,,f �' M � • . . _ '� G.j• area. F4;IV . QG''
do So C0,41j
ate- orvcid
0 f
0
Britt Paigo RENS
AUTHORIZED
AGENTS DATE: S412021
SIGNATURES:
i
IMPROVEMENT PERMIT,AUTHORIZATION TO CONSTRUCT,AND WELL CONSTRUCTION PERMIT:EACH THE IMPROVEMENT PERMIT,AVTHORi2ATM TO CONSTRUCT.AND WELL
CONSTRUCTION PERMIT ARE SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE ARE CHANGED FROM THOSE SHOWN ON THESE PERMITS.CHANGES FROM THE ABOVE
PERMITS REQUIRE ENVIRONMENTAL HEALTH APPROVAL.THE INSTALLERS SHALL BE REQUIRED TO HAVE AN IMPROVEMENT PERMIT,CONSTRUCTION AUTHORIZATION(BOTH VALID FOR 60
MONTHS FROM DATE IMPROVEMENT PERMIT 13 ISSUED),AND WELL PERMIT IF APPLICABLE BEFORE RISTALLDIG THE.:ABOVE SITE PLAN.
I